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WASHINGTON — States should plan for a flu pandemic much as coastal areas gear up for hurricanes: You act differently when a weak Category 1 storm's heading in than when a powerhouse Category 5 is offshore. The message is central to guidelines being released Thursday to help states prepare for the next worldwide outbreak of a super-flu.

Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

Old-fashioned infection control — nondrug measures such as voluntary quarantine or closing schools — is a cornerstone of those preparations, which are attempts to slow a pandemic's spread until vaccines become available.

But it is far from clear how well those measures would work or if some could cause more harm than good.

An Associated Press look in December at the nation's preparations found little agreement on best policies, even among neighboring states.

The new guidelines from the Centers for Disease Control and Prevention will not tell states what infection-control steps to take. But officials familiar with the document say it urges a tiered response that ratchets up depending on how bad the new flu is in each community — and reserves the most drastic actions for the worst outbreak.

Most preparations until now have focused on the worst-case scenario of a pandemic as severe as in 1918, when 50 million people worldwide died. But states should not race to close schools, for example, if the next pandemic is much less severe, like the one in 1968 that killed 1 million people.

"You kind of plan for the worst, but the odds are it won't be," said Dr. Robert Stroube, Virginia's health commissioner and president of the Association of State and Territorial Health Officials. "We're coming out with consensus so we don't have to reinvent it in every state throughout the country."

Federal health officials would not discuss important parts of the guidelines before their release Thursday.

But public health specialists cited one: During all but the least severe pandemic, when someone gets the new flu, everyone in that household voluntarily should stay home for seven days, That would help avoid spreading the virus before they realized that they, too, are sick.

'Self quarantine'
This approach is called "voluntary self quarantine." Questions about who should hole up and for how long have been debated hotly. With the official definition, communities should determine how they would deliver food and other necessities to such families, said Jeff Levi of the Trust for America's Health.

It also should spur state discussions about stockpiling extra doses of anti-flu medications for family members to take during that week of quarantine in hopes of warding off infection, Levi added.

Pandemics can strike when the easy-to-mutate flu virus shifts to a strain that people never have experienced. Scientists cannot predict when the next pandemic will arrive, although concern is rising that the Asian bird flu might trigger one if it starts spreading easily from person to person.

Diminishing pandemic's fallout
Keeping society functioning normally as long as possible diminishes a pandemic's economic fallout, and minimizes unintended consequences of infection-control steps. Closing schools means adults lose work to care for children and does not help if older kids sneeze on each other at the mall.

"The challenge to this (taking such steps) is finding the sweet spot of when to turn this on and turning this off," Dr. Martin Cetron, head of CDC's quarantine division, said Wednesday in Atlanta as agency scientists conducted a drill to practice how they would respond to a bird-flu outbreak.

The question is how well CDC will be able to judge the severity of a newly brewing pandemic — and then whether states and a worried public believe predictions that it will not be too severe, Levi said.

Federal officials are "concerned about pulling the trigger too fast" on these measures, he said.

Some states were developing similar tiered approaches, said Dr. Pascal James Imperato, a former New York City health commissioner who now directs public health at the State University of New York-Downstate Medical Center.

Thursday's document "elevates to a national level guidelines that can be used everywhere in the country," he said.

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